Painful Shoulder Conditions

The shoulder is known as being the most mobile joint in the body, but this does have its disadvantages. The large ranges of movement it can accomplish make it unstable and can cause shoulder problems to be a common occurrence. Shoulder injuries are common because the ball component in the upper arm of the joint is bigger than the socket it is positioned in. Also, unlike the hip, the shoulder socket is relatively shallow making the joint unstable. Tendons, ligaments and muscles support the shoulder joint and often injuries occur because such soft tissues becomes damaged, either due to overuse or underuse, an accident or a condition that causes gradual deterioration.

Shoulder pain is often localised but it is possible for pain to radiate to other parts of the body, including the arms, chest and back. It is also possible for health conditions, including heart disease, liver disease and gallbladder problems, to cause pain to travel to the shoulder joint via the nervous system.

How are shoulder conditions diagnosed?

There are various tests used to diagnose shoulder problems, but before a doctor performs an examination they will take a record of your medical history and ask about relevant symptoms. Tests include:

Physical examination: your doctor will examine your shoulder and move it in different directions to determine the extent of injury and assess your range of movement.

X-ray.

Magnetic Resonance Imaging (MRI): this test generates extremely detailed images of the interior of the body.

Arthrogram: this test involves dye being injected into the joint and evaluating X-ray images. The dye makes the outline of the shoulder joint highly visible and if the dye leaks into other areas this may point to a tear. It is also possible for dye to be blocked, which will show doctors that there is a blockage in an opening.

Additional diagnostic tests.

Shoulder dislocation

The shoulder is one of the most commonly dislocated joints in the body.

What is shoulder dislocation?

A shoulder dislocation occurs when the ball component of the joint comes away from the socket. In most cases a powerful force pulling the shoulder outwards causing the ball to dislodge leads to dislocation. Intense rotary motion of the joint can also cause dislocation, and it is common for the shoulder to be dislocated when a force leads the shoulder to be pulled backwards, especially if the muscles are not warmed up. As the shoulder is a joint that is unstable, once you have had a dislocation it is likely that you will have another. Sport players are at particular risk as their joints are under a lot of pressure. If you suffer from shoulder dislocation on a regular basis this is known as shoulder instability. It is possible for the shoulder to dislocate partially, which occurs when the upper arm is both in and out of the joint and is known as subluxation.

What are the symptoms of shoulder dislocation?

Dislocating the shoulder is extremely painful and this is one of the first signs. When a dislocation of the shoulder occurs, the position of the arm will change and may look abnormal. It is possible for the shoulder to dislocate downwards, forwards or backwards. Additional symptoms include:

Swelling.

Numbness.

Bruising.

Weakness in and around the muscle.

Restricted range of movement.

Dislocation can also cause damage to the soft tissues that support the joint, which may include tearing or straining the ligaments and tendons. Nerve damage may also be sustained, but this is not common.

What is the diagnosis process for a dislocated shoulder?

It is usually possible for doctors to diagnose a dislocated shoulder by examining the joint. X-rays can also be carried out to verify diagnosis and check for further damage.

What is the treatment process for a dislocated shoulder?

Treatment for a dislocated shoulder involves a procedure known as a reduction, which involves placing the ball back into the socket. Once the reduction has been carried out the arm will be immobilised using a sling or what is known as a shoulder immobiliser. The arm should be immobilised for several weeks and the patient rest to allow the joint to heal and prevent repeat dislocation. Once the shoulder joint is stronger a rehabilitation programme will begin, which involves exercises designed to strengthen the joint and soft tissue supporting the joint and increase the range of movement. Exercises may range from simple movements to weights.

Once the shoulder has been dislocated there is a higher risk of dislocation in the future, especially if the ligaments, tendons or muscles have been damaged severely. If the shoulder dislocates frequently surgery may be needed to repair torn ligaments or tighten ligaments that have stretched too far.

Surgery may be carried out in two different ways: open surgery or arthroscopy. An arthroscopy involves making a small incision in the joint and inserting an arthroscope to allow the doctor to look inside the joint. After the procedure the arm is immobilised for a period of around 6 weeks, but full recovery can take several months. Arthroscopic surgery is still relatively new and some surgeons prefer the traditional open surgery method. The risk of repeat dislocation is usually lower after open surgery, though it can take longer for full movement to be regained.

Shoulder separation

What is shoulder separation?

Shoulder separation occurs when the clavicle (the collarbone) does not meet the scapula (the shoulder blade) properly and when the calicle’s end does not reach the scapula. The separation occurs at the point where the two bones normally meet. It is caused by damage to the ligaments holding the joint in place, which may occur when ligaments are partially or entirely torn. The most common causes of shoulder separation are falling on a stretched out hand and a powerful hit to the shoulder joint.

What are the indicators of shoulder separation? How is it diagnosed?

Symptoms include pain in the shoulder, tenderness around the joint and, in less common cases, a raised bump above the AC joint (above the centre of the shoulder joint). Shoulder separation is often diagnosed using X-rays. A patient may be asked to hold a light weight during an X-ray to determine the severity of the injury, as holding the weight causes the muscles to pull slightly making separation more visible.

What treatment is performed for shoulder separation?

Shoulder separation is most often treated by resting the joint and using a sling. Applying ice to the area may also help to reduce swelling and pain (always ensure that you cover an ice pack with a cloth or towel to prevent skin damage). After the injury has healed an exercise programme will help to restore movement. In most cases the injury will heal fully without any further treatment within 2-3 months. However, if the ligaments are damaged severely surgery may be needed to repair the ligaments and grasp the clavicle in position. Surgery is only considered if the injury has not healed using other treatments.

Tendonitis, bursitis and impingement syndrome

Tendonitis, bursitis and impingement syndrome are closely linked and they can occur alone or together. Swelling of the bursa or rotator cuff can cause them to become trapped between the acromion and the humerus. Repeated movements over time involving the shoulder and general wear and tear may also cause the ligaments, muscles and tendons to become worn.

Tendonitis is a condition that occurs when the tendons become inflamed. In the case of tendonitis of the shoulder it is possible for the rotator cuff and bicep tendons to become swollen. Swelling may be mild, moderate or severe and is usually caused by other structures in the shoulder pressing on the tendon. If the rotator cuff tendon is inflamed and becomes thicker, this can cause it to become ensnared below the acromion. When the rotator cuff is pinched and squeezed this is known as impingement syndrome.

It is common for tendonitis and impingement syndrome to be accompanied by bursitis, a condition that occurs when the bursa sacs become swollen. The bursa sacs are designed to provide protection for the shoulder joint. Inflammation may be caused by conditions including rheumatoid arthritis or due to excess use of the shoulder, which may be a result of sporting activities or a job that requires repeated shoulder movements.

What are the symptoms?

Symptoms of tendonitis and bursitis include the gradual development of an ache in the upper arm and shoulder, which may become worse when you try to sleep on the affected area. Pain may also be experienced if the arm is extended upwards or from the body. If the bicep tendons are inflamed this usually causes pain in the shoulder and down the front of the arms. Inflammation often causes pain when you try and lift your arm upwards suddenly or the arm is pushed upwards forcefully.

What is the diagnosis procedure for these conditions?

When you see a doctor they will ask you about your symptoms and take a medical history. A physical examination is carried out to check for signs of inflammation and an X-ray may be ordered to rule out issues affecting the bones and arthritis. A sample of fluid from the joint may be taken and analysed to discount contamination. Impingement syndrome can usually be diagnosed when an injection of anaesthetic, called lidocaine hydrochloride, is injected into the gap under the acromion and it also reduces pain.

Treating tendonitis, bursitis and impingement syndrome

The priority when treating inflammation is to reduce swelling. This is done by applying ice, resting the joint and taking anti-inflammatory medication. In some cases an ultrasound is used to boost circulation and warm the deep tissue. Gentle exercises will also be introduced slowly.

If such treatment does not work a corticosteroid (steroid) injection may be given to the gap underneath the acromion. However, steroid injections have to be used with great caution because there is a risk of tendon rupture. If steroid injections are not successful and the injury has not healed after 6 months, open surgery or an arthroscopic may be carried out to repair tendons or alleviate force on the bursa or tendons.

Torn rotator cuff

What is a torn rotator cuff?

A torn rotator cuff occurs if the rotator cuff tendon tears. This can be caused by overuse injuries, heavy lifting, falling on a stretched out hand or due to general deterioration of the tendons causing them to weaken with age. The tendons are very strong and resistant but if worn down over time the risk of a tear gradually increases.

What are the symptoms of a torn rotator cuff?

In most cases people who have a torn rotator cuff suffer from pain in the deltoid muscles. These muscles are located at the top and side of the shoulders. Pain may get worse when you try and lift your arms or extend them outward, which means that simple everyday actions such as dressing can be painful. The shoulder may also feel much weaker than normal, especially when you try and raise your arm to a horizontal position. It is also possible to hear clicking and popping noises when the shoulder joint is moved into different positions.

What is the diagnosis procedure for a torn rotator cuff?

A doctor will ask the patient about their symptoms. Pain during rotary motion of the arm and weakness in the shoulder usually indicates a tear, but it may not be possible to diagnose a torn rotator cuff by physical examination alone. An MRI will detect a full tear but may not show a partial tear and X-rays often appear normal. If pain is reduced by injecting anaesthetic into the gap underneath the acromion this indicates impingement. If the injury does not respond to an injection of anaesthetic, the doctor may advise an arthroscopy to allow a look within the joint to reach a firm diagnosis.

Treatment for a torn rotator cuff

Treatments for a torn rotator cuff include rest, ice or heat therapy, pain relief and anti-inflammatory medication. The patient may also be advised to use a sling for a short period of time and additional therapies, such as ultrasound, cortisone injections and electrical stimulation. Exercises are gradually introduced to reinforce the shoulder joint and restore movement. If treatment is unsuccessful surgery may be needed to repair the tear, which can be done via open surgery or arthroscopic surgery.

Frozen shoulder (adhesive capsulitis)

What is a frozen shoulder?

A frozen shoulder occurs when an individual has severely restricted movement in their shoulder joint. A frozen shoulder, known as adhesive capsulitis by doctors, occurs most commonly because of an injury which leads to underuse of the joint. A frozen shoulder can also be caused by recent surgery on the joint and the progression of rheumatic diseases. Adhesions (bands of scar tissue) can also contribute to a frozen shoulder, as they restrict movement between the surfaces of the joint. A frozen shoulder usually occurs in conjunction with a deficiency of synovial fluid, which is used to lubricate the joint and facilitate movement. Adhesive capsulitis is usually distinguished from a stiff shoulder by the lack of room in between the ball of the humerus and the capsule. If you suffer from heart disease, rheumatoid arthritis, diabetes or lung disease, or you have had a stroke or been involved in an accident, you have a higher risk of developing a frozen shoulder. This condition is most common in people over the age of 40.

What are the symptoms of a frozen shoulder?

The main symptom of a frozen shoulder is the inability to perform simple actions that require extension of the shoulder. As the name suggests the shoulder literally feels like it is frozen in position. People often complain that pain is worse during the night.

How is a frozen shoulder diagnosed?

Most doctors will suspect a frozen shoulder immediately based on a physical assessment and symptoms. However, an arthroscopy may also be carried out to reach a firm diagnosis.

Treatment for a frozen shoulder

The aim of treatment is to restore movement to the shoulder. The first step is usually to take anti-inflammatory medication and use heat therapy and gentle exercises. In some cases TENS (transcutaneous electrical nerve stimulation) may be used. If other treatments are unsuccessful the shoulder may be manipulated under general anaesthesia. In some cases surgery may also be required to cut bands of scar tissue (adhesions).

Fracture

What is a shoulder fracture?

A shoulder fracture occurs when a bone is partially or completely cracked. Most fractures in the shoulder are caused by the impact of a powerful blow or a fall. Shoulder fractures usually involve the neckline of the humerus, which is located just under the joint ball or the clavicle (collarbone).

What are the symptoms of a shoulder fracture? How is diagnosis performed?

Shoulder fractures usually cause severe pain in the shoulder, which is quickly accompanied by bruising and inflammation. Fractures can be easy to spot because the bones are positioned abnormally. X-rays are used to confirm a fracture diagnosis and determine the severity of the fracture.

What does treatment for a shoulder fracture involve?

The aim of treatment for a fracture is to move the bones into the correct position and hold them in place. This will encourage healing and movement will be restored. Should the clavicle be broken the patient will be advised to put on a sling about the chest to hold it in position. Once the sling has been removed the patient will start an exercise programme to strengthen the bones and increase range of movement. It is uncommon for clavicle fractures to require surgical treatment.

If the collar of the humerus is fractured the arm will be immobilised using a shoulder immobiliser or sling. If the bones are not in the normal location surgery can be carried out to move them. Once the affected bone has healed exercise is done to strengthen the bone and surrounding tissues and increase mobility.

Arthritis of the shoulder

What is arthritis of the shoulder?

This is a degenerative condition (this means it gets gradually worse) that can affect several joints in the body. Arthritis is most common in older people but it can affect younger people. It can be caused by deterioration of the cartilage (known as osteoarthritis) or due to inflammation in one or more joints (known as rheumatoid arthritis). Arthritis is most commonly associated with the joints, but it can also affect the connective and supporting tissues, including the ligaments, muscles and tendons.

What are the symptoms of arthritis of the shoulder? How is diagnosis performed?

The most common symptoms of arthritis in the shoulder are decreased movement and pain, which tends to be felt above the AC joint. In most cases swelling is also visible. Arthritis can be verified by carrying out X-rays, but if your doctor suspects rheumatoid arthritis blood tests will also be carried out. Additional tests will probably be required to reach a concrete diagnosis. In some cases a sample of synovial fluid removed by way of the shoulder joint can also be analysed during the diagnostic process. An arthroscopy enables doctors to see inside the joint, but this is usually only carried out if surgery is being undertaken to repair damage to the cartilage, tendons or muscles.

If non-surgical treatments do not ease symptoms or the shoulder joint is severely worn causing parts of the joint to become loose, a procedure called an arthroplasty may be recommended. This is a joint replacement treatment which involves replacing the ball with a synthetic ball and placing a cap for the scapula (known as a glenoid). After surgery passive shoulder exercises will be carried out and involve another person moving the joint. After 3-6 weeks patients are advised to start exercising the joint independently. Exercises and stretches are an important part of recovery and help to increase strength, flexibility and mobility in the joint. The success of surgery is dependent on the state of the rotator cuff muscles before surgery and the patient’s commitment to the exercise regime.